A Daily Beer Drinker With Agonizing Gas and Back Pain

Erik D. Schraga, MD


February 09, 2021

Physical Examination and Workup

On physical examination, the patient is a thin, slightly emaciated man who is in obvious distress. His vital signs include a temperature of 95.7°F (35.4°C), a pulse of 87 beats/min, a respiratory rate of 28 breaths/min, a blood pressure of 111/62 mm Hg, and an oxygen saturation of 98% while breathing room air.

The patient is diaphoretic and is writhing around on his gurney. His sclerae are anicteric. The oropharynx is clear, with slightly dry mucous membranes. The heart examination reveals a regular rhythm, with no murmurs. The lungs are clear to auscultation in all fields, and no rales or rhonchi are found.

The abdominal examination is notable for exquisite tenderness in the epigastric and bilateral upper quadrant regions, with focal rebound tenderness and guarding. No tenderness or palpable masses are found in the patient's lower abdomen. The rectal examination reveals heme-negative, brown stool.

The patient is urgently placed on a cardiac monitor, and an 18-gauge peripheral intravenous (IV) line is inserted into the antecubital fossa, through which infusion of normal saline is initiated. The patient is given two doses of IV hydromorphone, without significant improvement in his pain or abdominal tenderness.

An upright, portable anterior/posterior chest radiograph is obtained; it appears normal, with no free air visualized under the diaphragm. Abdominal ultrasonography shows no evidence of gallstones or biliary wall thickening; the kidneys and liver appear normal as well.

All laboratory findings, including a complete blood cell count, metabolic panel, hepatic panel with amylase and lipase, and troponin levels, are within normal limits. An ECG reveals a normal sinus rhythm at a ventricular rate of 88 beats/min, with nonspecific ST flattening in the lateral leads and no change from the patient's prior ECG.

After the initial workup is completed, an additional dose of IV pain medication is administered to the patient, which provides some pain relief (although focal epigastric tenderness to palpation persists). The patient is prepped for CT of the abdomen and pelvis, and oral and IV contrast images are obtained (Figures 1 and 2).

Figure 1.

Figure 2.


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